You can fill out this application online and click 'submit' OR download the paper form (123K), print and mail it to:

Attn: Appeals and Correspondence, M/S BU148
Regence BlueShield
P.O. Box 2998
Tacoma, WA 98401-2998

Or by fax to: 1-877-663-7526

Please do not send any other paperwork or records at this time.

If you cannot access the online or paper forms, contact UMP Customer Service at 1-888-849-3681.